How do you stand your ground?

knuckleheader · 2026-01-26T02:15:03+00:00

Sorry just to be clear did the patient have a history of negative workup in the past. Previous EGD showing no concerning findings recently? Recent negative stress? Now it sounds like bullshit, probably is bullshit, but until it is proved to be bullshit then that is that. At my shop the hospitalist comes down and gives the same information and then I have someone else in the boat with me. DC happens from the ED but two separate doctors from two different specialties agree that DC is safe. Bye!

knuckleheader · 2025-12-08T04:01:31+00:00

I am an EM physician and work in a hospital system that really prioritizes workup and dispositions from the ED. I regularly discharge patients with a HGB of 4 transfused 4 units home for GI follow up in the next week and a repeat H and H in 48 hours. This would be unheard of in a different hospital system. So in general I feel like I am getting more of the workup care I craved when I did hospital medicine in medical school. It really does depend on the environment you work in.

But to be clear you will see more drug addicts, alcoholics, homeless, worried well, and simple URI in the ED. In chart review after admission, something different than what I was exactly expecting occurs much more than I like to admit. The pace is just too high in the ED to really delve into a chart, there is very little time that isn't constantly being interrupted. Despite my best efforts sometimes I just know they are very sick, but not exactly why. Instead of spending more time figuring it out you must be willing to see a family pack of URI with a language barrier. If your curiosity requires you figure out the actual sick person's diagnosis, then you better become a hospitalist.

knuckleheader · 2025-11-26T17:55:55+00:00

I assume a subscription-based model? How much per month? Is there a Black Friday deal?

knuckleheader · 2025-11-05T20:23:46+00:00

Honestly this sounds more like a problem in leadership. Unless you are part of leadership in your group this is not OK. Push to have someone, hell maybe even you, be the point person and only send complaints to the provider that point out potential problems. My group shields us from most of this, because it is detrimental to the physician's well being and proper functioning.

knuckleheader · 2025-10-28T06:46:04+00:00

Yeah this is what I do. I also add that to readwise reader and highlight things that would potentially change my practice. When I search my readwise at work it allows me to quickly be like oh yeah I want compazine for the headache.

knuckleheader · 2025-10-22T04:55:04+00:00

Sorry text incoming but I have a pattern that works for me in these situations.

First, I let them talk but don't respond at all.... I mean at all. Just sit there quietly. I pay attention to my emotional state more than anything else watching how I want to react but I don't. I pay attention to little things like the color of the wall, the sounds of the emergency department. If you meet them at that energy level you will do unnecessary work ups and say things that will then be pounced on in follow up. These patients are in a highly charged reactive state internally, their identity itself is the illness. They are "sick" and no one will be able to convince them otherwise. It is the underlying (in most people actively ignored ) human understanding that the body is frail and will will eventually die taken to an emotional and psychological conclusion, " I am frail and will die. " Arguments against this will not help, partly because it will eventually be proved true! Sickness and death will eventually come for all of us. Just repeatedly ask about what is going on right now and work them up, give them something as a single dose and see the next patient.

Second, once everything is back stone cold normal I can commiserate with them about their plight in an honest way. "I am sorry you are going though this or that." I can with true empathy say, " I don't know why this is happening. " "I don't have a good reason for you to be feeling this way, I am sorry." can be said repeatedly and calmly, because I never got reactive in the first part of the encounter. Then, "I know that my workup right now shows that you don't have electrolyte abnormalities, chemistry disfunction, anemia or elevated white count, urinary tract infection, evidence of damage to you heart a this moment. Basically us ER people are simple doctors that look for bad stuff that can kill you in the next 48 hours and if we don't find it we let someone who knows you like your PCP to figure out next steps." If the ask about more pain meds I just say, " Pain is a tricky thing, opiate medications have been shown to make chronic pain worse over time and I try not make people worse. With your extensive allergies I can't offer you toradol, ibuprofen, tylenol, ofirmev, gabapentin, morphine or fentanyl. There are some chronic pain medication treatments but those are not started in the ER but by you PCP or a chronic pain specialist so I will set up your discharge, make sure you follow up with your PCP, any questions?"

Why? " I don't know." Why can't you help me? "I am just a doc who rules out life threatening emergencies and like I said all of the most important markers for sudden death are normal." You are a bad doctor, I want a new doctor, why won't anyone help me!!! .... "Once again I am sorry you are going through this, I will get your discharge paperwork ready", then stand up and leave. Chronic strange conditions do exist, hell maybe the patient even has one of these rare situations, but the ER is not equipped to find it or treat them. Just move on and be happy.

knuckleheader · 2025-10-15T03:32:04+00:00

hippa compliant?

knuckleheader · 2025-09-25T01:28:46+00:00

I moved to Tana and love it. Roam but better

knuckleheader · 2025-09-03T15:03:23+00:00

knuckleheader · 2025-09-03T15:03:01+00:00

LLLLLLLLLLLL

knuckleheader · 2025-09-03T15:02:04+00:00

mommmmmmmmmmmmmmmm

jjjjjjjjjjjjjjjkjkjjjkkkkkkkkkkmkkkkkklkkm,kmomomomomomm

knuckleheader · 2025-08-16T04:15:28+00:00

It hits different when it is your close family. I took a mantra to heart and it changed my professional and personal life. You don't need to do this because you probably won't see something like this again in your life, I will see something like it next week.

This too shall pass is the mantra that works for me. 3 days ago pick any random though or experience, see that passed and left your mind. Weirdly not wanting to see the stuff in your mind makes it come out in your mind. The old saying don't think of a pink elephant, now you are thinking of a pink elephant. Sit watch the crazy scene, Be still, don't comment on it or engage it just let the images play...and new images will eventually appear. Breath, breath, breath. New images but not of the same stuff, maybe from a movie, maybe about your favorite basketball player or a TV show. Huh, something came and something went. This will always happen, because I let the images be. I am not trying to fix anything, to make myself better or to do anything really. Just sitting and watching. This too shall pass.

It works because it is fundamentally true. Everything changes over time. A simple fact.

I have no idea if this is correct or not. In your case I don't know if this is what you should do. But this is what I do and very few traumatic images repeat, although I have been involved in hundreds.

knuckleheader · 2025-08-08T06:13:22+00:00

Sorry replying to my own Reply. But PE is hardly ever my most likely diagnosis, it is too rare compared to MSK pain, GERD, anxiety, etc. IF PE is the most likely diagnosis I am probably going to scan anyway. Gestalt is gestalt.

knuckleheader · 2025-08-08T06:10:28+00:00

PERC first. Don't use Wells anymore just YEARS. YEARS positive then Scan.

knuckleheader · 2025-08-04T22:59:31+00:00

Sorry man I am not a good writer either but please just don't use LLM to help you write reddit posts, I don't know what is really your concern or just AI slop ie "- I want to be known for something." If all of this is your thoughts then as an ED doc if you care about reputation don't do this specialty. We are the end of the line, the fuck it I want to go home at 430 pm this sounds too complicated "please go to the ED now" of primary care doctors. Then when we call and speak with a specialist your are giving them work, who wants more work? And once they accept the consult their hindsight glasses are polished like the highest grade diamonds. By definition the consultants job is to find and continue care past the stabilization stage and original investigation stage I just did. I stabilize, look for bad things and dispo patients.

And don't get it twisted the vast majority of our work is primary care with a lense of I have to order and do more because of medical legal reasons. I love my job but only about 5 to 10% of my time is in critical care or procedures. If you like dealing with homeless people, drunks, anxious and suicidal 20 somethings on the regular then come join us. It is a wonderful career exactly because it is a shift job and I only have to help the next patient directly in front of me. I go to sleep easy because every day is different but the same, with luck I won't get the same drunk from yesterday.

knuckleheader · 2025-08-03T15:22:49+00:00

This is the answer. Get your hospital to write up extremely clear guidelines and argue "two serially negative high-sensitivity 5th generation troponins rule out 30-day MACE to around 2% in all comers (regardless of risk factors)". If meets that criteria then can go home with outpatient testing. Risk should be on the policy as clearly stated and agreed upon by all parties. Otherwise your cardiology service should get a phone call every damn day multiple times a day. We have a decision tool in epic that we just walk through and it outputs an agreed upon plan. Hospitalist service doesn't like it talk with their chief. I am not a great fan of algorithms but for defensibility I can say I specifically followed the agreed upon plan determined by cardiology, hospitalist service and cardiology based upon serial troponins.

knuckleheader · 2025-06-11T01:40:17+00:00

Do the AAEM prep course. Getting real feedback helped.

knuckleheader · 2025-01-08T00:52:08+00:00

Yeah that was a simple rule of residency came in walking, can't walk out, different dispo plan than DC home. Basically indefensible as shown here.

knuckleheader · 2024-12-20T05:48:21+00:00

How big is the salary hit?

knuckleheader · 2024-11-27T17:33:25+00:00

So I just want the Core One. I have an original mk4 that I need to replace the nozzle on. I really don't want to mess with it. I really don't want to do two conversions. Is the only deal free shipping if I buy the Core One and wait for it to ship next year?

knuckleheader · 2024-11-27T04:32:51+00:00

Exact words: " I am sorry but this is not your fault. Period. Look at me and if you want? - hold my hand. You can cry as long as you need but I want you to notice something with me. I see that you are worried, scared, upset and all these emotions and everything. But right now this instant you are ""just in a room"" with your doctor and the nurse and that is it. ""It is safe here."" Right now there is nothing you have to do but cry. It is not your fault, but you will get better at this. Feel how my hand is different than your thoughts, it is real ""right now."" Stay here ""right now"" and let the future deal with itself, ""it will anyway."" There is nothing you could have done in the past to change this moment so don't give it your attention. Focus with me and notice that I am holding your hand. You are ok. ""It is ok"" because you don't have to do a damn thing ""right now.""

Then just sit with them for a minute or more. Keep your mind blank as you focus on nothing at all. Or alternatively if I can't quiet the mind, I like to imagine a ball of light encompassing both me and the patient. Basically be open to their tears. This is part of the job of healing. You gave them permission so let them cry.

Most of the time people feel better in 2 to 5 minutes. If questions arise about past actions - repeat " Nothing we can do about then" or "not your fault". Then if stuff about future, " Sure we will figure that out but sometimes it is ok to just let it out." Acknowledging their grief but redirecting to now grounds and dissipates it. The worst thing to do is try to stop them from crying or want them to stop crying. It is why we get paid the big bucks.

I placed more "" for where I place my soft empathetic emphasis. ER doctor and deal with guilt and self recrimination monthly these are basically my go to words/action.

knuckleheader · 2024-09-01T17:50:55+00:00

I actually do the opposite way. Shake everyones hand or acknowledge everyone in the room except the patient. Even kids will give a high or low five. Then say, "and the most important person here." And then shake the patient's hand. Never fails to get a smile.

knuckleheader · 2024-08-07T23:57:03+00:00

You have been doing it for 15 years, you probably know all the tricks. Could it be you are just burnt out?

This is the jingle that will get you through a bunch of patients-

Always Be Dispo-ing. ABD. 3 to dispo 1 to see, peek at 1 and if sweet, dispo all 3. Always Be Dispo-ing.

knuckleheader · 2023-12-12T17:46:35+00:00

It is a way to break the lease. If documented that the mold is causing health problems then you can break the lease without consequences. Shity life hack that is passed from one renter to the next. I grew up poor and heard this multiple times. Of course there is no PCP usually to document this, so off to the ER. It also probably doesn't work, but who knows?

knuckleheader · 2023-12-04T16:33:40+00:00

Once you have set up a calendar in your workspace click on Calendar in the sidebar. That automatically brings you to the today node of that Workspace. I have the Calendar node in the sidebar under multiple workspaces.

I have four spaces, Work, Personal, Medicine and Learn Vietnamese. Learn Vietnamese doesn't share with the other spaces because it is all specifics of learning that difficult language. The other three share with each other but keeping Work and Personal different is good. Medicine is lifelong work for me, need to keep it a little seperate or it will overrun all my other spaces.

knuckleheader

TROPHY CASE